The June #JHSJC was a great way to kick off the summer! We thank everyone who joined us, especially our European colleagues who participated again in the second round! This month, we discussed two articles from the June 2021 issue of The Journal of Hand Surgery: Structural Versus Nonstructural Bone Grafting for the Treatment of Unstable Scaphoid Waist Nonunion Without Avascular Necrosis: A Randomized Clinical Trial and Evaluation of PROMIS’ Ability to Detect Immediate Postoperative Symptom Improvement Following Carpal Tunnel Release.
Feel free to continue the conversation below in the comments! And please check out previous #JHSJC transcripts (please scroll to the bottom of the page).
J Hand Surg Am- ASSH @JHandSurg:
June’s first #JHSJC starts now! Let’s get the discussion going.
Brent Graham @BgTalkinman:
Welcome to the June edition-1st session. We will convene again tomorrow at 4 pm EDT, 8 pm GMT so feel free to join in then as well! #jhsjc
Let’s start with article 1: https://www.jhandsurg.org/article/S0363-5023(21)00097-6/fulltext #jhsjc
Brent Graham @BgTalkinman:
This was a level I #RCT. Were there any methodologic issues noted? #jhsjc
RyanC @RPCalfeeSTL:
I was glad to see cancellous do well as that is my go to #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
That is interesting bc I have never used it! #jhsjc
Brent Graham @BgTalkinman:
Did anyone note any issues with the way the study was performed – randomization, outcomes etc? #jhsjc
Warren @whammert to @BgTalkinman and @RPCalfeeSTL:
I use both, but from radius and very rarely iliac crest for scaphoids #jhsjc
RyanC @RPCalfeeSTL:
like Warren I get from radius #jhsjc
Brent Graham @BgTalkinman to @whammert and @RPCalfeeSTL:
I have never done a case that WASN’T ICBG! Regional variation! #jhsjc
Brent Graham @BgTalkinman:
It looks like the shape of the scaphoid should dictate the mode of bone grafting. Is that appropriate or one bone graft type for all? #jhsjc
Warren @whammert to @BgTalkinman:
I guess it depends on cancellous vs cortical. I am not sure iliac crest would fit a scaphoid better for me. #jhsjc
Brent Graham @BgTalkinman:
With cancellous graft is it possible to reconstruct the shape of scaphoid? #jhsjc
Given that this is a level I #RCT is this a definitive answer for how #scaphoid #non-union should be managed wrt to bone graft type? #jhsjc
Warren @whammert to @BgTalkinman:
I just compress the graft in a syringe and then pack into the void, so I think the scaphoid shapes the graft more #jhsjc
No perfect study, but this was well designed. I think there will be variability in measurements they used #jhsjc
Brent Graham @BgTalkinman:
We have a study that showed cancellous grafts and a locking plate gave good results https://www.jhandsurg.org/article/S0363-5023(17)31630-1/fulltext #jhsjc
Brent Graham @BgTalkinman:
Does that mean that the type of bone graft or the mode of internal fixation is more important? #jhsjc
Warren @whammert to @BgTalkinman:
I have not taken the leap to put a plate in. I am not sure I could get the screws to stay in the bone #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree completely. It’s not something I’ve ever considered. #jhsjc
Warren @whammert to @BgTalkinman:
my take is with adequate stability, graft type is less important. Same reason as two screws working #jhsjc
RyanC @RPCalfeeSTL:
I haven’t had one where plate seemed to fit #jhsjc
Brent Graham @BgTalkinman to @whammert:
I agree that there was no real difference on the proportion healed but the diff in rate of malunion seemed to be definitive or even 1 screw. #jhsjc
Warren @whammert to @BgTalkinman:
I am just happy when they heal. #jhsjc
Brent Graham @BgTalkinman to @whammert:
I have taken the same view even with AVN cases – stability is the most important factor IMHO. #jhsjc
RyanC @RPCalfeeSTL:
also happy with healing. Yet to change a malunion with more surgery #jhsjc
Brent Graham @BgTalkinman:
If there is collapse would you use a cancellous graft with screws? This study showed a much greater risk of malunion. #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
I have done a few corrective osteotomies, including in an NHL player who played another 8 years. I think it works. #jhsjc
Warren @whammert to @BgTalkinman:
this is when I use cortical strut as described by Steve Lee and Scott Wolfe #jhsjc
Brent Graham @BgTalkinman to @whammert:
Is that like a Russe graft? #jhsjc
Warren @whammert to @BgTalkinman:
They calm it a hybrid Russe – one screw and one cotrical strut #jhsjc
Brent Graham @BgTalkinman:
I have to commend these authors on a well thought out and implemented #RCT. I would love to see more like it! #jhsjc
Warren @whammert to @BgTalkinman:
yes – a lot of work went into this study #jhsjc
Brent Graham @BgTalkinman:
Let’s move on to article 2: https://www.jhandsurg.org/article/S0363-5023(21)00102-7/fulltext #jhsjc
I interviewed @whammert for the monthly podcast here: https://www.jhandsurg.org/pb/assets/raw/Health%20Advance/journals/yjhsu/June_2021.mp3 #jhsjc
Brent Graham @BgTalkinman:
This one has a lot of potential ramifications. #jhsjc
There was a simple but important question: do the PROMIS scales pick up early improvement after #CTR? #jhsjc
Not unexpectedly, there was a lot of immediate clinical relief within 2 weeks but almost all the PROMIS scales showed worse status #jhsjc
Warren @whammert to @BgTalkinman:
sleep is one of the fist things to improve and these PROMIS instruments don’t measure that #jhsjc
Brent Graham @BgTalkinman to @whammert:
I was just typing the question “Why?” but you’ve answered that. Is that reflected in the #BCTQ? #jhsjc
Warren @whammert to @BgTalkinman:
yes and probably would be in any instrument that looks at sleep – including PROMIS Sleep #jhsjc
Daniel A. London, MD MS @LondonDA:
I can see this finding having potential relevance to other clinical entities and how we measure outcomes. But does assessing early outcomes matter from an a) research perspective, b) clinical care perspective for the individual patient, or c) both? #jhsjc
Brent Graham @BgTalkinman:
We have had another study (https://www.jhandsurg.org/article/S0363-5023(18)30310-1/fulltext) in 2019 showing a similar finding. #jhsjc
Should the PROMIS scales be limited to use for longer-term results? #jhsjc
Warren @whammert to @BgTalkinman:
at least for carpal tunnel. We are looking at some other conditions that seem to show pretty quick improvement #jhsjc
Brent Graham @BgTalkinman to @whammert:
This is important bc payers may ask for a measure of “quality” in treatment. PROMIS may not do. Agree? #jhsjc
RyanC @RPCalfeeSTL:
I agree. For ctr any outcome other than just asking numb/tingling or sleep confounded by early surgery soreness #jhsjc
Brent Graham @BgTalkinman:
Some of the PROMIS scales have also been shown to have other performance issues like ceiling effects – DASH has that as well. #jhsjc
Given some emerging limitations, does PROMIS need more development? #jhsjc
Warren @whammert to @BgTalkinman:
PRIOMIS can be used for quality, but need time to recover from surgery and that will vary with procedures #jhsjc
Brent Graham @BgTalkinman:
Is this a question of an inadequate question bank for some of the PROMIS scales? #jhsjc
RyanC @RPCalfeeSTL:
I think this issue a general one. PROMIS just being carefully evaluated and highlighted here #jhsjc
Brent Graham @BgTalkinman to @whammert:
Agreed – so disease specific scales early, PROMIS for aggregates and longer-term results? #jhsjc
Warren @whammert to @BgTalkinman:
I don’t think the question bank is inadequate – although UE has a ceiling. it is choosing the right instrument condition #jhsjc
I don’t think MHQ, DASH, or PRWE would do any better early, so condition specific better early #jhsjc
Brent Graham @BgTalkinman to @RPCalfeeSTL:
By “general” do you mean affecting all scales that might be used in this context? #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
yes – scales in this context if not disease specific scale
Brent Graham @BgTalkinman to @whammert:
If you were advising a payer interested in this, what would you recommend? #jhsjc
How about a disease status instrument like #BCTQ? #jhsjc
Warren @whammert to @BgTalkinman:
you need more than one data point and time point to determine quality #jhsjc
Works for CTS and UNE, but not for other things, so practical for research, but not routine care #jhsjc
Brent Graham @BgTalkinman to @whammert:
What about #BCTQ? #jhsjc
Brent Graham @BgTalkinman to @whammert:
That is a very important point but I worry that insight may not be clear to payers asking the questions. #jhsjc
Warren @whammert to @BgTalkinman:
Agree, but everything should be taken in context. I think looking at PROMIS sleep next #jhsjc
Brent Graham @BgTalkinman:
What is the role of single item scales here like #SANE (https://www.jhandsurg.org/article/S0363-5023(20)30182-9/fulltext) and “hand normality” (https://www.jhandsurg.org/article/S0363-5023(21)00089-7/fulltext)? #jhsjc
Warren @whammert to @BgTalkinman:
I think there is merit. The easier the questionnaire, the more likely to get it done. But will have limitations #jhsjc
Brent Graham @BgTalkinman:
I can see those being used for admin purposes like show a high altitude view of “good” or “bad” and other scales for research. #jhsjc
Brent Graham @BgTalkinman:
It’s an excellent, timely study and I know we will be seeing more of the same before we know the place of each of these. #jhsjc
RyanC @RPCalfeeSTL:
everything has compromise – more info but more burden, generalize across conditions or specific, short question but less details #jhsjc
Brent Graham @BgTalkinman:
What is encouraging is the amount of interest I see in measurement in general. These are critical subjects. #jhsjc
RyanC @RPCalfeeSTL to @BgTalkinman:
agree! #JHSJC
Brent Graham @BgTalkinman:
We can’t make progress if we don’t agree on what is working and what isn’t. Good measures help that! #jhsjc
Warren @whammert to @BgTalkinman:
Accepting limitations of each is important as well, which was one of the key points #jhsjc
RyanC @RPCalfeeSTL to @whammert and @BgTalkinman:
yes – all are good measures – none perfect but nothing in medicine is perfect #jhsjc
Brent Graham @BgTalkinman:
Okay! We are just about at the end of our hour. We will be on a summer hiatus until Sept 14. Thanks to everyone for joining in! #jhsjc
J Hand Surg Am- ASSH @JHandSurg:
Please join us for a second #JHSJC discussion on June 9th at 8 pm GMT (4 pm EDT)!
Ryckie Wade @ryckiewade:
Welcome to the June JHS Journal Club (#jhsjc) – Round 2!
Ryckie Wade @ryckiewade:
1st up – PROMIS and early CTR ? https://www.jhandsurg.org/article/S0363-5023(21)00102-7/fulltext – what are your thoughts, people? #jhsjc
Ryckie Wade @ryckiewade to @whammert @mrjnrodrigues @conrad_harrison @LukeGeog1 and @JCRWormald:
Is this expected? PROMs pros, what are your thoughts? https://www.jhandsurg.org/article/S0363-5023(21)00102-7/fulltext #jhsjc
Jenny Lane @jennifercelane to @ryckiewade, @whammert, and 4 others:
yes! I want to learn more about PROMIS and how this work feeds into our understanding of its uses #jhsjc
Ryckie Wade @ryckiewade:
Most said they were “better” within days/weeks of #CTR, but CAT PROMIS UE/PI/PF scores appeared to worsen ? #jhsjc
Jenny Lane @jennifercelane:
they had really good rates of questionnaire response post operatively- that is something not easy to achieve #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
They felt that was related to the immediate effects of surgery, not the symptoms of #CTS #jhsjc
Brent Graham @BgTalkinman to @jennifercelane:
Their anchor question was just one item. They obtain the #PROMIS scores on all patients that come to the clinic. #jhsjc
Brent Graham @BgTalkinman
What is used in the UK/Eur to measure results of #CTR? #jhsjc
Is the Boston Carpal Tunnel Syndrome Questionnaire (#BCTQ) used? #jhsjc
Jenny Lane @jennifercelane to @BgTalkinman:
but to have full completion post operatively too- that’s not something that is always achieved #jhsjc
Brent Graham @BgTalkinman to @jennifercelane:
They do all the scales every visit. That is quite common in many clinics in the US. #jhsjc
One of the advantages of #PROMIS is its feasibility and the computer adaptive testing. #jhsjc
There is always a tradeoff between the richness of data provided by a scale and feasibility of having pts fill it in. #jhsjc
Ryckie Wade @ryckiewade to @BgTalkinman:
as I understand (anyone correct me, pls), PROMIS UE is midst translation/validation in the UK… #jhsjc
Jenny Lane @jennifercelane to @BgTalkinman:
quite- CAT within #PROMIS definitely seems to have its advantages! #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
Hopefully it doesn’t really require translation because of course it is in English. #jhsjc
Brent Graham @BgTalkinman to @jennifercelane:
There are some CAT-based version coming out for legacy scales too. #jhsjc
Ryckie Wade @ryckiewade:
We acquire PROMIS UE/pain routinely for our nerve patients. On paper though… Look forward to the UK CAT version! #jhsjc
Brent Graham @BgTalkinman to @ryckiewade:
That is definitely a barrier. #jhsjc
Brent Graham @BgTalkinman to @jennifercelane:
Here is a recent paper in @JHandSurg on that topic: https://www.jhandsurg.org/article/S0363-5023(20)30617-1/fulltext #jhsjc
Ryckie Wade @ryckiewade to @BgTalkinman and @jennifercelane:
CAT legacy scales? Great. This might be useful for the UK Hand Registry #jhsjc
Brent Graham @BgTalkinman:
That is important for demonstrating “quality” in some circumstances and PROMIS prob shouldn’t be used for that. #jhsjc
Ryckie Wade @ryckiewade to @Lisa_Newington, @kwb_doc, and 3 others:
Thanks @Lisa_Newington, this is really valuable –> could you join us at tchat.io and use the #jhsjc so your input is captured & visible to all??
Brent Graham @BgTalkinman:
Condition-specific disease status scales are probably best for showing early improvement. #jhsjc
Jeremy Rodrigues @mrjnrodrigues:
BCQ and other condition specific measures may align with “is condition better”, but none of promis tools used here reflect that construct. They encapsulate more, inc postop pain #JHSJC
Brent Graham @BgTalkinman to @mrjnrodrigues:
There is a #PROMIS sleep scale that I learned about from @whammert author of this study. That should be considered if #PROMIS is to be used to eval early post-#CTR outcomes. #JHSJC
Jeremy Rodrigues @mrjnrodrigues:
I’m also curious about the choice of MCID for promis. We can all be a bit laissez-faire about the difference between MCID and MCIC. This study ideally needed MCIC. It’s a different concept. #jhsjc
Brent Graham @BgTalkinman to @mrjnrodrigues:
Tell me what you think is the difference because I’m never entirely sure I understand the distinction. #jhsjc
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
MCIC is “how much improved I need to be for my op to be worth it”.
MCID is “how much difference in my improvement [I can still be improved] vs the guy next 2 me in clinic who had the other op, b4 I wish I had had his op”
Reinier Feitz @ReinierFeitz to @mrjnrodrigues and @BgTalkinman:
Totally agree, it is all about the anchor, 1/3 methods to calculate, and of course correct for the happy population we operate in general, flooring effects…. The deeper we dive, the more I am at a loss..
Brent Graham @BgTalkinman to @ReinierFeitz and @mrjnrodrigues:
I favour the approach of anchoring MCID to a patient response, like these authors have done in the past. That seems the most meaningful to me among the approaches available. #JHSJC
Brent Graham @BgTalkinman:
The bottom line for this paper is that PROMIS wasn’t sensitive to important early changes after #CTR #jhsjc
Jeremy Rodrigues @mrjnrodrigues:
Unclear who says these are “important changes”? The Q posed is “is your condition better?” Patients may answer with “yes paraesthesia gone but I’m crippled by wound infection”. Is this better? Only cognitive debriefing would inform how patients answered
Brent Graham @BgTalkinman to @mrjnrodrigues:
It’s true – they were specifically asked about the symptom that led to the surgery – most of the improvement was around nocturnal numbness and sleep disruption. Hopefully an acute surgical complication would be clear. #jhsjc
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
Agree, I used an extreme example. But many might still have wound pain/healing at first postop, affecting promis score
Brent Graham @BgTalkinman to @mrjnrodrigues:
That was exactly their conclusion and they interpreted that as not necessarily helpful. #JHSJC
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
but is it unhelpful? It represents the true patient state and whether they are getting on with life. Improvement in carpal tunnel symptoms alone arguably simply massage our surgical ego #JHSJC
Brent Graham @BgTalkinman to @mrjnrodrigues:
I don’t understand. The goal was to ask about the effect of treatment on #CTS symptoms in the 1st 2 wks. Seemingly that is a reasonable thing to ask – no consideration of surgeon ego. Do you not agree? #JHSJC
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
Disagree. Aim is to globally improve the patient, i.e. relieve the symptoms, without causing them a bunch of new ones from the treatment. Focusing only on the first of these can ignore iatrogenic insult. #JHSJC
Brent Graham @BgTalkinman to @mrjnrodrigues:
Had the study been done 3 months after sx, I suspect that the result would have been “global improvement”. However, that wasn’t the objective of the study. They wanted to see how PROMIS performed in the early phases. #JHSJC
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
I agree with this. But I think 3 month would have been a more useful study overall. And clearer to interpret.
Brent Graham @BgTalkinman to @mrjnrodrigues:
that wasn’t the objective. There are a lot of studies showing the effects of #CTR using many different measures after 3-6 months. #JHSJC
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
I know. But I’m trying to think how I’d use info about day 9 postop perceived improvement? Going back to quality of surgery, either final outcome or complications more useful? #JHSJC
Brent Graham @BgTalkinman to @mrjnrodrigues:
The concern in many places, most notably the US, is that payers and others will define “quality” for a common procedure like #CTR by the immediate outcome. This just shows that PROMIS shouldn’t be used for that. #JHSJC
Jeremy Rodrigues @mrjnrodrigues to @BgTalkinman:
I know. But I’m trying to think how I’d use info about day 9 postop perceived improvement? Going back to quality of surgery, either final outcome or complications more useful? #JHSJC
Brent Graham @BgTalkinman to @mrjnrodrigues:
Of course, longer-term outcomes are probably more important and there are a lot of studies on that. The focus of this study was something more pertinent to the demonstration of “quality” than #CTS rx outcomes. #JHSJC
It isn’t necessarily about how you would use that information, but rather how administrators and payers will use it in judging you. That might not be an issue in the UK but it is in many places, especially the US. #JHSJC
The concern in many places, most notably the US, is that payers and others will define “quality” for a common procedure like #CTR by the immediate outcome. This just shows that PROMIS shouldn’t be used for that.
Exactly! that’s why they specifically asked about the symptoms rather than focus on the cost of doing business there – post-op pain reflected in the decreased PROMIS scores. #JHSJC
What I meant by “unhelpful” was that the goal of documenting early improvement of the symptoms wasn’t met by an unresponsive scale, PROMIS.
Ryckie Wade @ryckiewade to @mrjnrodrigues and @BgTalkinman:
Thanks so much @mrjnrodrigues – what tool(s) would be ideal for early outcomes after CTR? Where does (if at all) PROMIS UE fit into the CTR assessment? #JHSJC
Ryckie Wade @ryckiewade
Lets move onto the 2nd paper – #RCT of different iliac bone grafts for #scaphoid non-union https://www.jhandsurg.org/article/S0363-5023(21)00097-6/fulltext #jhsjc
Brent Graham @BgTalkinman:
IMO this was a well-performed #RCT on a practical topic. #jhsjc
Ryckie Wade @ryckiewade:
Awesome to see a well executed #RCT in #handsurgery ? But were there any methodologic concerns people spotted? #jhsjc
Brent Graham @BgTalkinman:
What kind of bone grafting is used for #scaphoid #non-unions in UK/Eur? #jhsjc
Jenny Lane @jennifercelane to @ryckiewade:
good work- wake up the trialists! #jhsjc
Brent Graham @BgTalkinman:
Should the nature of the bone graft de dictated by the presence/absence of scaphoid collapse? That is what is implied. #jhsjc
Most surgeons just use one type of bone graft for all cases. I done possibly hundreds of #scaphoid #nonunions all #ICBG #jhsjc
Justin Wormald @JCRWormald to @ryckiewade:
the sample size calc raises concerns – calculation on four outcomes? Exactly 49? Which happens to be the n after drop out #jhsjc
Also can’t see evidence of a priori protocol or trial registration – raises further concerns re methodology #jhsjc
Brent Graham @BgTalkinman to @JCRWormald:
They claimed there was no drop out of patients. #jhsjc
Brent Graham @BgTalkinman to @JCRWormald:
I agree that isn’t in the paper. Was there something that raised your concern? #jhsjc
Justin Wormald @JCRWormald:
…also outcome assessment un-blinded #jhsjc
Brent Graham @BgTalkinman to @JCRWormald:
I don’t think that is correct. The Methods describe blinded evaluators of the radiographic data. #jhsjc
Justin Wormald @JCRWormald to @BgTalkinman:
quite right! Missed that.
Brent Graham @BgTalkinman to @JCRWormald:
You are incorrect that they didn’t do a sample size estimate – they did. There was also block randomization. These are fundamental questions asked at an early stage of editing for all our submissions. #jhsjc
Justin Wormald @JCRWormald to @BgTalkinman:
Misunderstanding, I said they performed a sample size calc but based on four ‘primary’ outcomes #jhsjc
Not criticising editorial process – just never seen a sample size calc done like that before, my understanding was that it’s done on a single primary outcome to determine effectiveness
Brent Graham @BgTalkinman to @JCRWormald:
They did their sample size estimate for the various radiographic parameters and DASH. It is in the 1st sentence Under “Statistical Analysis” #jhsjc
the best trials should be powered for a number of outcomes thought to be pertinent. Many that just focus on the primary outcome are underpowered for secondary outcomes. That doesn’t seem to have been the case here. #JHSJC
Justin Wormald @JCRWormald to @BgTalkinman:
Precisely – so which outcome was used to determine a sample size of 49 in each arm? qDASH, time to union or others? #JHSJC
Brent Graham @BgTalkinman @JCRWormald:
Read the 2nd sentence under “Statistical analysis”. #JHSJC
Justin Wormald @JCRWormald to @BgTalkinman:
Again I agree they’ve performed sample size calc, but they’ve done one calc for 10% change across four distinct outcomes, which I’ve not seen before, and it’s resulted in the exact number of study participants after screening and loss to follow-up #jhsjc
Justin Wormald @JCRWormald to @BgTalkinman:
Always reassuring to see check planned primary outcome, proper a priori sample size calc to determine effect for that outcome, and definitions of adverse outcomes
Without protocol, hard to be sure no selective outcome reporting etc IMO
Brent Graham @BgTalkinman to @JCRWormald:
Let’s say this: In my 6 yrs in this job I’ve seen a surprising amount of dishonesty. This didn’t raise concerns with me. #jhsjc
Justin Wormald @JCRWormald:
Finally getting to go through a #handsurgery RCT with @BgTalkinman in #JHSJC – there aren’t many but there will be more!
Justin Wormald @JCRWormald to @BgTalkinman and @FACTSstudy1:
SSI 4-6% – fits with typical SSI risk in prospective RCTs in hand trauma, interestingly lower quality studies report lower SSI rates #jhsjc
Although I may be skeptical about this, put it through @cochranecollab risk of bias and would come out as high risk
Brent Graham @BgTalkinman to @JCRWormald, @FACTSstudy1, and @cochranecollab:
I don’t agree with you. All studies are biased, even #RCT. In the grand scheme of knowledge on this topic, this adds much more than the majority of what has been written on the subject. Readers should interpret accordingly. #JHSJC
Maybe, but I attribute that to it being conducted in what is an authoritarian society. Draw whatever conclusions you want from that but I don’t have your skepticism about it.
Ben Dean @bendean1979:
The authors should be congratulated. It’s a hard trial to do. They’ve added to the evidence base. We’ll done. #JHSJC
Ryckie Wade @ryckiewade:
Many thanks to everyone who participated in the discussion – that concludes tonight’s session. #jhsjc
